While it works on a cellular level, one wonders what it might do to a real heart...Bzzzaaaaaapppppp....
-Wes
Image reference.
Friday, May 30, 2008
A Lab-Based Optical Pacemaker
While it works on a cellular level, one wonders what it might do to a real heart...Bzzzaaaaaapppppp....
-Wes
Image reference.
Thursday, May 29, 2008
The Astrophysics of Surgery
When the moon is in the Seventh House
And Jupiter aligns with Mars
Then peace will guide the planets
And love will steer the stars.
-"Age of Aquarius," by the 5th Dimension
Scheduling surgery can be tricky:
"I'm sorry, doctor, I can't get my pacemaker then."
"Why not?"
"Mars is in retrograde."
-Wes
Wednesday, May 28, 2008
The First Real Hospital Quality Measure
How many hospital measures exist for physicians today? Answer "119." (Somehow I count 134, but hey, what's the difference)
Now, how many hospital measures exist for hospitals today? Answer: 35.
But these quality measures for hospitals, are really clinical measures for physicians, so all told, physicians now have 155 quality measures to which they must conform, should they want to be paid.
The bottom line is that hospital quality measures, as they exist today, are really more physician quality measures.
But hospitalists are paid by hospitals, and as such, have now become a "hospital quality standard." Same with nocturnists - hospitalists that do the night shift. Heck, these used to be medical students and residents, but because of the ever-growing concern over sleep deprivation in medicine, residents' hours may soon be restricted to 56 hours a week. With the growing realization of the paucity of care delivery after hours, coupled with the reality of the need for 24/7 care, hospitals are now in the position to differentiate themselves with a measure that can actually affect outcomes.
So, here's my proposal for the first real hospital quality measure (always looking for ways to cut the bureaucracy):
Does the hospital employ full time hospitalist and nocturnist services?
The next might be clinical nursing staff to patient census ratios.
Once we stop confusing hospital quality measures with physician quality measures, we might get somewhere.
-Wes
Now, how many hospital measures exist for hospitals today? Answer: 35.
But these quality measures for hospitals, are really clinical measures for physicians, so all told, physicians now have 155 quality measures to which they must conform, should they want to be paid.
The bottom line is that hospital quality measures, as they exist today, are really more physician quality measures.
But hospitalists are paid by hospitals, and as such, have now become a "hospital quality standard." Same with nocturnists - hospitalists that do the night shift. Heck, these used to be medical students and residents, but because of the ever-growing concern over sleep deprivation in medicine, residents' hours may soon be restricted to 56 hours a week. With the growing realization of the paucity of care delivery after hours, coupled with the reality of the need for 24/7 care, hospitals are now in the position to differentiate themselves with a measure that can actually affect outcomes.
So, here's my proposal for the first real hospital quality measure (always looking for ways to cut the bureaucracy):
Does the hospital employ full time hospitalist and nocturnist services?
The next might be clinical nursing staff to patient census ratios.
Once we stop confusing hospital quality measures with physician quality measures, we might get somewhere.
-Wes
Tuesday, May 27, 2008
EKG Du Jour - # 8: The Case of Abdominal Pain
A 77 year old woman with a long-standing history of Crohn's colitis presents to the ER for left lower quadrant abdominal discomfort, nausea, and loose stools for a week. She denied fever, chills, syncope, lightheadedness, palpitations, or chest discomfort, but did have a "fall" three days prior to admission at home whose circumstances were unclear to her. She has a long-standing history of coronary artery disease with preserved left ventricular function and atrial fibrillation. She received an AV nodal ablation and dual-chamber permanent pacemaker implantation in 2001. She had not made her last two pacemaker clinic follow-ups "because I just felt too bad to go."
Her medications, which were not changed, included metoprolol 50 mg daily, Lasix 40 mg daily, and warfarin.
Examination demonstrated normal vital signs with the exception of an irregular pulse, and a cardiovacular examination with a fixed split second heart sound. Her abdomen demonstrated a slightly tender left lower quadrant without rebound, normal WBC count, and her stools did not contain blood.
Here's her EKG:
She was seen by the GI service, who felt her history and examination was most consistent with a Crohn's disease flair and began her on a Prenisone taper (40 mg daily for three days and tapering over 2 weeks until off).
Her internist wasn't sure about the EKG and asks you to evaluate her.
What do you tell him? Plan?
-Wes
Her medications, which were not changed, included metoprolol 50 mg daily, Lasix 40 mg daily, and warfarin.
Examination demonstrated normal vital signs with the exception of an irregular pulse, and a cardiovacular examination with a fixed split second heart sound. Her abdomen demonstrated a slightly tender left lower quadrant without rebound, normal WBC count, and her stools did not contain blood.
Here's her EKG:
Click image to enlarge
She was seen by the GI service, who felt her history and examination was most consistent with a Crohn's disease flair and began her on a Prenisone taper (40 mg daily for three days and tapering over 2 weeks until off).
Her internist wasn't sure about the EKG and asks you to evaluate her.
What do you tell him? Plan?
-Wes
Monday, May 26, 2008
Happy Memorial Day
As we gather with friends and family to cook the bratwurst, hamburgers, chicken or ribs and taste the cole slaw or potato salad washed down by a refreshing frosty one, take a moment to click on a name and remember what others have sacrificed for our freedom and way of life.*-Wes
*Warning: Kleenex alert. I couldn't take it after viewing a couple of these. God Bless America.
Image reference.
Sunday, May 25, 2008
What Doctors Do at National Meetings
Here's a cool time-lapse movie of the comings and goings at the ACC in New Orleans in 2007:
Kind of reminds me of Brownian motion in the physics lab.
-Wes
Kind of reminds me of Brownian motion in the physics lab.
-Wes
Saturday, May 24, 2008
The Dog and His Master
Good dog. Sit. Siiittt.
Now, I see you use claims-based reporting to Medicare.
Gooooooddddd.
Just fill out three or more measures of 80% of your "applicable" patients OR one measure for 30 consecutive patients OR one measure for 80% of your "applicable" patients for the entire year.
Adda boy!
Now fetch that paperwork. Fill it out.
That's my dog!
Now, check the calendar. Still before 1 July?
Goooood. You can qualify for the whole biscuit still! Whew!
And did you see, CMS has increased the number of "measures" from 74 to 119 just to make it easier for you, boy!
Sit! Now sssiiiiiittttt. Don't try to get up boy. Don't do runnin' off after that ol' 'coon boy. That's it. That's a good internal medicine dog. Don't you see boy? You make about $200,000 a year, and if you behave and do those tricks, I'll give you that biscuit we've been talkin' about. But you gotta behave, boy! Do what I tell you.
Yep, I got you that Special $3-K biscuit!
Oooop. Stay boy! Why you runnin' off? Damn it boy! Stay! How many times I gotta tell you? You don't mind your manners, and we're gonna put you back in your cage, dammit!
What's that? Why you growlin' boy? We're just tuggin' your leash a little. Oh I know, I know, you see 70 patients a week for 40 weeks a year. You know, it's a about a buck a patient... Come on, boy! That's it, boy. Fill out that paper work! Document it! Document that you documented it.
Gooooddd. What a good quality-based purchasing dog!
Ooop, I see you missed one of your 30-in-row patients, boy. Sorry, no biscuit for that one. Maybe you'll hit the 80% mark of all your other patients with that measure.
What's that, boy? Not sure which one your measurin'? Oh now, now, don't worry. Just measure, boy. See the biscuit? Yep, I still have it! Adda boy, keep workin', boy!
What a good dog!
What the...??? Where the hell you goin', boy? Get back here! Get BACK here! DAMN IT! I work my butt off to train these damn dogs and they up an bolt to the hospitals. Every frickin' time.
Oh, well. He'll come back. Hunger and our hospital rankin's have a way of doin' that.
-Wes
Now, I see you use claims-based reporting to Medicare.
Gooooooddddd.
Just fill out three or more measures of 80% of your "applicable" patients OR one measure for 30 consecutive patients OR one measure for 80% of your "applicable" patients for the entire year.
Adda boy!
Now fetch that paperwork. Fill it out.
That's my dog!
Now, check the calendar. Still before 1 July?
Goooood. You can qualify for the whole biscuit still! Whew!
And did you see, CMS has increased the number of "measures" from 74 to 119 just to make it easier for you, boy!
Sit! Now sssiiiiiittttt. Don't try to get up boy. Don't do runnin' off after that ol' 'coon boy. That's it. That's a good internal medicine dog. Don't you see boy? You make about $200,000 a year, and if you behave and do those tricks, I'll give you that biscuit we've been talkin' about. But you gotta behave, boy! Do what I tell you.
Yep, I got you that Special $3-K biscuit!
Oooop. Stay boy! Why you runnin' off? Damn it boy! Stay! How many times I gotta tell you? You don't mind your manners, and we're gonna put you back in your cage, dammit!
What's that? Why you growlin' boy? We're just tuggin' your leash a little. Oh I know, I know, you see 70 patients a week for 40 weeks a year. You know, it's a about a buck a patient... Come on, boy! That's it, boy. Fill out that paper work! Document it! Document that you documented it.
Gooooddd. What a good quality-based purchasing dog!
Ooop, I see you missed one of your 30-in-row patients, boy. Sorry, no biscuit for that one. Maybe you'll hit the 80% mark of all your other patients with that measure.
What's that, boy? Not sure which one your measurin'? Oh now, now, don't worry. Just measure, boy. See the biscuit? Yep, I still have it! Adda boy, keep workin', boy!
What a good dog!
What the...??? Where the hell you goin', boy? Get back here! Get BACK here! DAMN IT! I work my butt off to train these damn dogs and they up an bolt to the hospitals. Every frickin' time.
Oh, well. He'll come back. Hunger and our hospital rankin's have a way of doin' that.
-Wes
More Fun at MedTees
I just finished putting a few new suggested designs that passed our "highly selective" peer-review process on MedTees.
One is for ladies with celiac disease, shown here:
But my new favorite might be this for post-hysterectomy patients:
What do you think? Got another one?
-Wes
One is for ladies with celiac disease, shown here:
But my new favorite might be this for post-hysterectomy patients:
What do you think? Got another one?
-Wes
Friday, May 23, 2008
The $1.9 Million Shout-Out
Yep, the cost of a one-day ad campaign by the Centers for Medicaid and Medicare Services to promote their hospital rankings:
-Wes
Officials there are spending $1.9 million for a one-day advertising blitz in 58 local markets, including Chicago, urging consumers to compare the quality of care at medical institutions.I wonder why they have to advertise? Aren't people using these rankings? I mean, they're so helpful and save money, no?
-Wes
Thursday, May 22, 2008
Saying Goodbye to High School
Well done, buddy.
-Wes
Addendum: 23 May 2008 @ 1505 CST: Wow, this just in. No wonder I felt better today...
Today's Healthcare: The Davids vs the Goliaths
This is a first in a series of "point-counterpoint" debates between myself and Pete and Matt over at MarketIntellNow - a blog devoted to the promotion of e-health, the Electronic Medical Record, and the Patient Medical Record. Our topics will revolve around three areas:
1. Consumer-Driven Healthcare-- crock or crusade?
2. Doctor and hospital ratings-- fad or phenomenon?
3. John & Jane Doe-- patients or consumers?
I'm starting, then they'll counter, then I get a rebuttal, and so forth. Hopefully, it'll be entertaining and informative. Feel free to join in and make your thoughts known (I don't mind being handed my fanny once in a while.)
Unfortunately, I have to go first, so here goes...
* * *
Pete and Matt are right. E-health is all about the patient. Really it is.
After all, the Goliaths of Business tell us so.
You know them: Google, Microsoft, Walmart, Walgreens, IBM, Aetna, UnitedHealth, MedCo, Blue Cross, Quest Diagnostics and many, many many others. All told, as of 20 May 2008, the valuation of these companies alone exceeds $953 billion (yes, that’s right, nearly one trillion) dollars: a sum that is half the entire domestic product of all of China and a formidable sum to even begin to comprehend.
You the Consumer
With that purchasing power, we are now only too happy to hear that they are all about health, too. No doubt some of this corporate response is driven by the need to simplify an abysmally complex healthcare delivery system and Byzantine medical billing systems. But just as probably because the nation’s healthcare tab exceeds $2.3 trillion dollars and represents a rich cornucopia of new revenue streams. So, like knights with really shiny armor, each is ready to swoop down to rescue the healthcare system and its "consumers" with nothing but pure beneficence as their goal. Yes, dear patients, they’re all about you, the "consumer" and your "wellness."
After all, you are entitled to any healthcare you want. You deserve the best, the newest, the shiniest, the most plush accommodations. Anytime, anywhere, 24/7. You, dear consumer, can have it all. Oh, it might cost you a bit, sure. But our ever-friendly insurers are here to help with that. Just please, keep “consuming,” for when you consume healthcare services, you feed the beast that feeds our new economy. Our business partners will be sure to provide the information about your choices for hospitals and doctors and testing facilities for “screenings” and “prevention” right at your fingertips. And because they know that each state has different rules and different insurance policies, they’ll even allow you to filter the choices by where you live!
But that’s not all. Many will also provide you with the “best” hospitals and rehab facilities for your care, complete with rankings, too. No doubt they’ll steer you to the plan that suits you and your budget, dear consumer, the best. Have fun choosing. (Just be sure to make the right choice, will you, lest you be stuck paying a $105,000 cover charge for your cancer treatment.)
So they make websites. Quite expensive websites. Unfortunately, these websites might not save costs to our healthcare system, but heck, who cares? It's all about you, the healthcare consumer computer-surfer, remember? After all, they won't be built with the Goliath's money, mind you, but yours. Personal Health Records and informational sites. Tons and tons of them. Some better organized than others – some with pleasing color schemes and most with lots of smiling faces. And each of these sites will promise to house healthcare needs (and portions of your medical record) under one roof, provided you give your “permission.” For some, you can even grant other pharmacy, laboratory and hospital services to upload your medication, laboratory, and procedural information, too – all neatly organized. What's not to like?
But God help you if you make a typographical error or your name is a common one like John Smith (he'll need his Social Security Number and date of birth to differentiate himself from the other John Smiths out there – while providing yet another exposure for identity theft – but, hey, the information will just be used for healthcare – and maybe a bit of advertising). You see, unique identifiers are a challenge to healthcare databases. It’s tough to know you’ve got the right “John Smith” when databases are shared. The wrong “merge” and voila, you got a whole new set of preexisting conditions that the insurers can use to crank your premiums. Who will help rectify the situation? What about the other “John Smith’s” privacy? Oops.
Rankings Schmankings
True, Personal Health Records and informational websites can have answers to your questions. They have forums. They have information on your doctors and hospitals – like credentials and rankings. But these rankings are created by many, many sources: the government, marketing firms, and advertisers. Each of these ranking systems have significant limitations and use criteria that are non-uniform and only intermittently updated and almost never verified. (That, my friends, would take innumerable man-hours to maintain.) But they all claim they are the best at helping you choose your doctor or hospital with no proof as to their effectiveness. * Sigh *
Now is there a ranking that identifies the quality doctors based on the time they take with you, or if they answer your questions, or act as your advocate or evaluates your actual treatment outcomes? No. Instead, we are told that "quality doctors" are the ones that give aspirin 100% of the time after a heart attack, or prescribe beta blockers for heart failure. THAT, my friends, is just two of the ever-expanding 119 major measures that we should strive for! And these same rankings are often used for marketing of healthcare facilities. Heck, some hospitals with carefully collected quality assurance measures even pay to have their doctors “ranked” since their data always looks so good! All to help you, dear consumer, to make the right choice. After all, it is much easier (and politically correct) to implement e-health initiatives that hire more bureaucrats than to simplify the bureaucracy and redundancy by cutting unnecessary jobs!
Oh, and yes, they own all of the data. Your healthcare data.
That’s right, not you. Them.
And the Goliaths carry nary a liability concern regarding its accuracy – you saw that disclaimer, didn’t you? And don't forget, all of this data is no longer officially protected by the Health Insurance Portability and Accountability Act. Bits and bytes galore, all whirring this way and that for any number of eyes to see. All without any recourse or tracking capability and all at the speed of light. Because you, my friend, have authorized "sharing." But that’s not all. On some sights you’ll be targeted with advertisements to "empower" your healthcare choices. For many companies, this is the business model for their survival. So just how “secure” is your healthcare information if keywords you’ve entered are triggering the ads placed on your webpage? And although the Goliaths want to compare the security of banking transactions to healthcare transactions, are not the issues of identity theft real for both types of transactions? Correcting your widely disseminated “personal record” after it's been compromised is nearly impossible once the imprint of a preexisting conditions exists on your record. Good luck contacting Google to straighten that out.
The Goliaths, my friends, may soon become the Great and Powerful Oz of Healthcare, conveniently hiding their liability (and profit motives) behind a great electronic curtain called the Internet.
The PMR is not the EMR
But we mustn’t be too harsh. There are really good aspects to the personal health record and informational websites. Where else is there universal ability to transport your healthcare information between disparate institutions? Where else can you get a relatively unbiased search of information? Where else can you empower yourself with an avalanche of mostly reliable information and share experiences with total strangers who may have endured your same ordeal. But we mustn’t confuse the Personal Health Record, editable by all, as an Electronic Medical Record (EMR). The EMR contains the official transcript of your healthcare received. The EMR is the ultimate arbiter of healthcare delivery that is the undisputed king of records used in liability proceedings. As such, there is little incentive for physicians to maintain two sets of records. The Personal Health Record is just that: personal. It is NOT a health record. Sorry.
And if you want to have a Personal Health Record, you’d better not be too sick. If you can’t type or see, Personal Health Records and computer-driven healthcare might not be in your best interest, but there certainly might be a place for a caregiver to follow your healthcare delivery. Personal health sites leave a huge gap for services since they assume all "patient-consumers" use or have access to computers and will shop for “healthcare” like the latest dress or are physically and emotionally capable to use the sites as intended.
And what does this Goliathian healthcare look like on the ground? I'm just not sure yet. One only needs to look at the recent unfortunate recent circumstances of Senator Ted Kennedy to begin to comprehend the issues.
Imagine. Senator Kennedy comes into the ER with confusion, obtundation, and maybe not moving his right side very well. Did the doctors rush to Google and type in his symptoms? Oh, they could have. And they would have been met with a differential diagnosis of 870 different entries with AIDS, Creutzfeldt-Jakob disease, and inflammatory disease of the brain as the first three results after only 0.35-0.48 seconds. Hardly an accurate assessment, as we’ve seen.
And what about those hospital rankings to choose a hospital? Did the Kennedy's have a choice where he went first? Not really. He was appropriately taken to the closest facility. But more importantly as WhiteCoat has already pointed out, the family opted not to stay at that “Top 100” hospital, but rather elected to transfer him to an unranked hospital: Massachusetts General Hospital. So given all the different ranking systems out there, which ranking mechanism will you, dear “consumer,” use to make your choice of healthcare facility? Could it be that these marketing gimmicks called “rankings” might not have your best interests in mind?
And how about his diagnosis? Did a website help drill the hole in his skull and pass the biopsy needle in to his brain? Oh sure, I bet you could find pictures of how it’s done on the internet, but when it came to performing the procedure and delivering the care, where were Google, IBM, and Microsoft on this one?
Finally, when it came time to break the news of the diagnosis to Senator Kennedy and his family, were these corporate Goliaths in the room hold hands and lend support and nurturance? Hardly. Did the family consult the wellness bureaucrats to plan the next steps when anxiety was high and trust and respect are critical?
No, it was the Davids of healthcare – the doctors and their patients – that did the dirty, yet critically important, work together. It is the Davids that form the cellular basis of the healthcare system – the cornerstone upon which the entire dysfunctional system rests - not a computer, or a website, or a hospital, or an insurer.
And disease happens. It happens while doctors are filling out the 119 items on the EMR to keep their ranking. It happens while patients are typing in their website that redirects money and attention away from the front-line care. The doctor-patient relationship is threatened like never before. With fewer primary care physicians and more and more “physician” extenders, the word “doctor” has now been replaced with “provider.” Should we spend millions on information technology infrastructure while ignoring the resources required for the than the hands-on, “mano-a-mano,” aspects of healthcare that are so critically needed today? I guess the philosophical discussion comes down to what medicine is all about. Is it about the money? Or is it about the care of the patient?
Unfortunately, it’s probably about both, for if we run out of money, we can no longer care for patients. I acknowledge the Goliaths' potential to impose dramatic market forces to control costs if they could generate healthcare price transparency. But will the hospitals and insurers ever end their little profitable healthcare pricing collusion schemes and make their closely held data available for all to see?
But when I get sick, it’s going to be all about me. And I admit, when I get sick, I might turn to Google to show me some possible diagnoses, or to list side-effects or drug interactions that might occur with my medications, or to keep that list up to date, as long as my fingers will be able to pound on a keyboard. But despite how much information gets pumped to me, I will still need a doctor with experience to help guide me toward the best course of treatment for me – one who can cull through the morass and has seen and touched someone with my condition before. Knowledge, judgement, and experience trump mere information and marketing every time in healthcare.
While some information is important, websites won’t fill the patient care void in healthcare that exists today. Certainly, they'll fill a few gaps that exist. And perhaps our goal should be to strive for "concierge medicine at Wal-Mart prices" (h/t KevinMD). Will PMR's and EMR's and home monitoring services permit this? Where's the profit in that for all those Goliaths?
E-health initiatives, therefore, are one just one more tool for the patients, the doctors, and the marketers. And while Electronic Medical Records do improve efficiencies on many levels: data retrieval, billing and coding compliance, accounts receivable, etc., but they do not treat patients nor always have their best interests at heart. Does this Great and Powerful Oz really provide something that will save us? Or does he provide bells and whistles while medicine becomes less and less humanistic? For instance, do we really need daily complete blood counts and electrolyte measurements in our default admission order sets? Certainly the hospitals benefit with higher revenues. Or might less frequent labs suffice? How much has this single default order set cost our patients? How much has it saved in terms of earlier detection of infections? No one knows.
But we do know that a doctor sifting through pages and pages of Personal Medical Record information will have less time at the bedside. We do know that there will be legal exposures if that data presented is incomplete or incorrect. So the debate goes on. But one thing is for sure, before we spend millions and millions on websites that are still unproven to reduce costs or improve care, we better be damned sure that we’re spending our limited healthcare resources wisely in the name of “Computer-Driven Healthcare.”
-Wes
Addendum: 11:30 AM CST 23 May 2008 - Matt's rebuttal is up. What'dya think?
1. Consumer-Driven Healthcare-- crock or crusade?
2. Doctor and hospital ratings-- fad or phenomenon?
3. John & Jane Doe-- patients or consumers?
I'm starting, then they'll counter, then I get a rebuttal, and so forth. Hopefully, it'll be entertaining and informative. Feel free to join in and make your thoughts known (I don't mind being handed my fanny once in a while.)
Unfortunately, I have to go first, so here goes...
Pete and Matt are right. E-health is all about the patient. Really it is.
After all, the Goliaths of Business tell us so.
You know them: Google, Microsoft, Walmart, Walgreens, IBM, Aetna, UnitedHealth, MedCo, Blue Cross, Quest Diagnostics and many, many many others. All told, as of 20 May 2008, the valuation of these companies alone exceeds $953 billion (yes, that’s right, nearly one trillion) dollars: a sum that is half the entire domestic product of all of China and a formidable sum to even begin to comprehend.
You the Consumer
With that purchasing power, we are now only too happy to hear that they are all about health, too. No doubt some of this corporate response is driven by the need to simplify an abysmally complex healthcare delivery system and Byzantine medical billing systems. But just as probably because the nation’s healthcare tab exceeds $2.3 trillion dollars and represents a rich cornucopia of new revenue streams. So, like knights with really shiny armor, each is ready to swoop down to rescue the healthcare system and its "consumers" with nothing but pure beneficence as their goal. Yes, dear patients, they’re all about you, the "consumer" and your "wellness."
After all, you are entitled to any healthcare you want. You deserve the best, the newest, the shiniest, the most plush accommodations. Anytime, anywhere, 24/7. You, dear consumer, can have it all. Oh, it might cost you a bit, sure. But our ever-friendly insurers are here to help with that. Just please, keep “consuming,” for when you consume healthcare services, you feed the beast that feeds our new economy. Our business partners will be sure to provide the information about your choices for hospitals and doctors and testing facilities for “screenings” and “prevention” right at your fingertips. And because they know that each state has different rules and different insurance policies, they’ll even allow you to filter the choices by where you live!
But that’s not all. Many will also provide you with the “best” hospitals and rehab facilities for your care, complete with rankings, too. No doubt they’ll steer you to the plan that suits you and your budget, dear consumer, the best. Have fun choosing. (Just be sure to make the right choice, will you, lest you be stuck paying a $105,000 cover charge for your cancer treatment.)
So they make websites. Quite expensive websites. Unfortunately, these websites might not save costs to our healthcare system, but heck, who cares? It's all about you, the healthcare consumer computer-surfer, remember? After all, they won't be built with the Goliath's money, mind you, but yours. Personal Health Records and informational sites. Tons and tons of them. Some better organized than others – some with pleasing color schemes and most with lots of smiling faces. And each of these sites will promise to house healthcare needs (and portions of your medical record) under one roof, provided you give your “permission.” For some, you can even grant other pharmacy, laboratory and hospital services to upload your medication, laboratory, and procedural information, too – all neatly organized. What's not to like?
But God help you if you make a typographical error or your name is a common one like John Smith (he'll need his Social Security Number and date of birth to differentiate himself from the other John Smiths out there – while providing yet another exposure for identity theft – but, hey, the information will just be used for healthcare – and maybe a bit of advertising). You see, unique identifiers are a challenge to healthcare databases. It’s tough to know you’ve got the right “John Smith” when databases are shared. The wrong “merge” and voila, you got a whole new set of preexisting conditions that the insurers can use to crank your premiums. Who will help rectify the situation? What about the other “John Smith’s” privacy? Oops.
Rankings Schmankings
True, Personal Health Records and informational websites can have answers to your questions. They have forums. They have information on your doctors and hospitals – like credentials and rankings. But these rankings are created by many, many sources: the government, marketing firms, and advertisers. Each of these ranking systems have significant limitations and use criteria that are non-uniform and only intermittently updated and almost never verified. (That, my friends, would take innumerable man-hours to maintain.) But they all claim they are the best at helping you choose your doctor or hospital with no proof as to their effectiveness. * Sigh *
Now is there a ranking that identifies the quality doctors based on the time they take with you, or if they answer your questions, or act as your advocate or evaluates your actual treatment outcomes? No. Instead, we are told that "quality doctors" are the ones that give aspirin 100% of the time after a heart attack, or prescribe beta blockers for heart failure. THAT, my friends, is just two of the ever-expanding 119 major measures that we should strive for! And these same rankings are often used for marketing of healthcare facilities. Heck, some hospitals with carefully collected quality assurance measures even pay to have their doctors “ranked” since their data always looks so good! All to help you, dear consumer, to make the right choice. After all, it is much easier (and politically correct) to implement e-health initiatives that hire more bureaucrats than to simplify the bureaucracy and redundancy by cutting unnecessary jobs!
Oh, and yes, they own all of the data. Your healthcare data.
That’s right, not you. Them.
And the Goliaths carry nary a liability concern regarding its accuracy – you saw that disclaimer, didn’t you? And don't forget, all of this data is no longer officially protected by the Health Insurance Portability and Accountability Act. Bits and bytes galore, all whirring this way and that for any number of eyes to see. All without any recourse or tracking capability and all at the speed of light. Because you, my friend, have authorized "sharing." But that’s not all. On some sights you’ll be targeted with advertisements to "empower" your healthcare choices. For many companies, this is the business model for their survival. So just how “secure” is your healthcare information if keywords you’ve entered are triggering the ads placed on your webpage? And although the Goliaths want to compare the security of banking transactions to healthcare transactions, are not the issues of identity theft real for both types of transactions? Correcting your widely disseminated “personal record” after it's been compromised is nearly impossible once the imprint of a preexisting conditions exists on your record. Good luck contacting Google to straighten that out.
The Goliaths, my friends, may soon become the Great and Powerful Oz of Healthcare, conveniently hiding their liability (and profit motives) behind a great electronic curtain called the Internet.
The PMR is not the EMR
But we mustn’t be too harsh. There are really good aspects to the personal health record and informational websites. Where else is there universal ability to transport your healthcare information between disparate institutions? Where else can you get a relatively unbiased search of information? Where else can you empower yourself with an avalanche of mostly reliable information and share experiences with total strangers who may have endured your same ordeal. But we mustn’t confuse the Personal Health Record, editable by all, as an Electronic Medical Record (EMR). The EMR contains the official transcript of your healthcare received. The EMR is the ultimate arbiter of healthcare delivery that is the undisputed king of records used in liability proceedings. As such, there is little incentive for physicians to maintain two sets of records. The Personal Health Record is just that: personal. It is NOT a health record. Sorry.
And if you want to have a Personal Health Record, you’d better not be too sick. If you can’t type or see, Personal Health Records and computer-driven healthcare might not be in your best interest, but there certainly might be a place for a caregiver to follow your healthcare delivery. Personal health sites leave a huge gap for services since they assume all "patient-consumers" use or have access to computers and will shop for “healthcare” like the latest dress or are physically and emotionally capable to use the sites as intended.
And what does this Goliathian healthcare look like on the ground? I'm just not sure yet. One only needs to look at the recent unfortunate recent circumstances of Senator Ted Kennedy to begin to comprehend the issues.
Imagine. Senator Kennedy comes into the ER with confusion, obtundation, and maybe not moving his right side very well. Did the doctors rush to Google and type in his symptoms? Oh, they could have. And they would have been met with a differential diagnosis of 870 different entries with AIDS, Creutzfeldt-Jakob disease, and inflammatory disease of the brain as the first three results after only 0.35-0.48 seconds. Hardly an accurate assessment, as we’ve seen.
And what about those hospital rankings to choose a hospital? Did the Kennedy's have a choice where he went first? Not really. He was appropriately taken to the closest facility. But more importantly as WhiteCoat has already pointed out, the family opted not to stay at that “Top 100” hospital, but rather elected to transfer him to an unranked hospital: Massachusetts General Hospital. So given all the different ranking systems out there, which ranking mechanism will you, dear “consumer,” use to make your choice of healthcare facility? Could it be that these marketing gimmicks called “rankings” might not have your best interests in mind?
And how about his diagnosis? Did a website help drill the hole in his skull and pass the biopsy needle in to his brain? Oh sure, I bet you could find pictures of how it’s done on the internet, but when it came to performing the procedure and delivering the care, where were Google, IBM, and Microsoft on this one?
Finally, when it came time to break the news of the diagnosis to Senator Kennedy and his family, were these corporate Goliaths in the room hold hands and lend support and nurturance? Hardly. Did the family consult the wellness bureaucrats to plan the next steps when anxiety was high and trust and respect are critical?
No, it was the Davids of healthcare – the doctors and their patients – that did the dirty, yet critically important, work together. It is the Davids that form the cellular basis of the healthcare system – the cornerstone upon which the entire dysfunctional system rests - not a computer, or a website, or a hospital, or an insurer.
And disease happens. It happens while doctors are filling out the 119 items on the EMR to keep their ranking. It happens while patients are typing in their website that redirects money and attention away from the front-line care. The doctor-patient relationship is threatened like never before. With fewer primary care physicians and more and more “physician” extenders, the word “doctor” has now been replaced with “provider.” Should we spend millions on information technology infrastructure while ignoring the resources required for the than the hands-on, “mano-a-mano,” aspects of healthcare that are so critically needed today? I guess the philosophical discussion comes down to what medicine is all about. Is it about the money? Or is it about the care of the patient?
Unfortunately, it’s probably about both, for if we run out of money, we can no longer care for patients. I acknowledge the Goliaths' potential to impose dramatic market forces to control costs if they could generate healthcare price transparency. But will the hospitals and insurers ever end their little profitable healthcare pricing collusion schemes and make their closely held data available for all to see?
But when I get sick, it’s going to be all about me. And I admit, when I get sick, I might turn to Google to show me some possible diagnoses, or to list side-effects or drug interactions that might occur with my medications, or to keep that list up to date, as long as my fingers will be able to pound on a keyboard. But despite how much information gets pumped to me, I will still need a doctor with experience to help guide me toward the best course of treatment for me – one who can cull through the morass and has seen and touched someone with my condition before. Knowledge, judgement, and experience trump mere information and marketing every time in healthcare.
While some information is important, websites won’t fill the patient care void in healthcare that exists today. Certainly, they'll fill a few gaps that exist. And perhaps our goal should be to strive for "concierge medicine at Wal-Mart prices" (h/t KevinMD). Will PMR's and EMR's and home monitoring services permit this? Where's the profit in that for all those Goliaths?
E-health initiatives, therefore, are one just one more tool for the patients, the doctors, and the marketers. And while Electronic Medical Records do improve efficiencies on many levels: data retrieval, billing and coding compliance, accounts receivable, etc., but they do not treat patients nor always have their best interests at heart. Does this Great and Powerful Oz really provide something that will save us? Or does he provide bells and whistles while medicine becomes less and less humanistic? For instance, do we really need daily complete blood counts and electrolyte measurements in our default admission order sets? Certainly the hospitals benefit with higher revenues. Or might less frequent labs suffice? How much has this single default order set cost our patients? How much has it saved in terms of earlier detection of infections? No one knows.
But we do know that a doctor sifting through pages and pages of Personal Medical Record information will have less time at the bedside. We do know that there will be legal exposures if that data presented is incomplete or incorrect. So the debate goes on. But one thing is for sure, before we spend millions and millions on websites that are still unproven to reduce costs or improve care, we better be damned sure that we’re spending our limited healthcare resources wisely in the name of “Computer-Driven Healthcare.”
-Wes
Addendum: 11:30 AM CST 23 May 2008 - Matt's rebuttal is up. What'dya think?
Tuesday, May 20, 2008
EKG Du Jour - # 7
"Hey, Dr. Wes, I was reading EKGs and saw one of your patient's EKG today. The pacemaker was doing something funky and I was wondering if you could check it out:"
So what's going on? Is this normal or not?
-Wes
Click image to enlarge
So what's going on? Is this normal or not?
-Wes
Star Wars, Episode IV: A New Hope?
Upon returning from the Heart Rhythm Society Meeting, I strapped in.
User ID: * click click click click *
Password: * click click click click click click *
Good morning Master Luke.
In-basket: 250 e-mails, Order Cosign: 324; Results Review: 124…
Use the Force, Luke!
* click click click click click click click click click *
But I, I can’t, ugh, I’m trying… * click click click click click *
… Phone Calls: 2; ED Follow-up: 9, Overdue Results: 32…
Come on, Luke! Focus!. Use the Force!…
… Pre-surgery notification: 34; Staff message: 3; Review reports: 2...
Small chirping sounds are heard from behind my seat. Then a voice: “Master Luke, I think C3PO has been hit!”
Focusing now…
“Urology Grand Rounds will be held 5/15/2008 at…” * click *
“Employee Appreciation Day…” * click *
“New opportunities to learn Word, Excel…” * click *
“Link Update: …” * click *
“Canceled: Clinical Section Meeting 5/21/08…” * click *
“Epic Downtime Notice…” * click *
Yes, Luke, Yes!
* click click click click click click click *
Smoke clearly perceived from back of computer guidance system… “Master Luke, our engine! What are we going to do? You’re needed in the lab, then the ward! There’s just too many of them!”
* click click click click click *
The Force Luke! Use the Force!
“Leadership Conference to be held..." * click *
“Google Alert: Google Health launched to great acclaim. Patients now will have their own personal health records and soon they may be able to communicate directly with their doctor via e-mail…”
“Noooo! I'm not sure I can... There’s too many! Ugh!” * click * “Ugh! I’m… trying…” * click *
The Force, Luke!!!
* click *
* click *
.
.
.
* click *
.
.
.* click *
Would you like to Log Off?
Yes, Luke, that’s it!!!!! Now, Luke, N…O…W…!!!!!
Closing his eyes...
* click *
Then a moment later:
* Bbbbzzzaaaappppppp *
A large flash occurs, then the screen goes dark… then...
silence....
Yes, Jedi Master. On to rounds now…
... and may the Force be with you.
-Wes
Monday, May 19, 2008
Women's Heart Health: The Perils of Nonconformity
According to the American Heart Association, Minneapolis, MN, home of all three of the major medical device manufacturers (Medtronic, Boston Scientific, and St. Jude Medical) was the most "heart friendly" city in their recently-released ranking of the most Heart Friendly Cities for Women.*
Nashville, TN was heralded as the worst city. (St. Louis, Detroit, Pittsburgh, Dallas-Fort Worth-Arlington, Columbus, Cincinnati, Las Vegas, Cleveland and Indianapolis round out the loser list.)
Wow.
Now cities have rankings compiled by donation amounts to the American Heart Association! Go Red!
So come on now, Nashville and other bastions of womanly insensitivity. Stop being so policitally incorrect! Get your act straight, for goodness sake! Take it from us guys. Conform.
Or else you're going to keep getting, er, well, um, publically bitch-slapped by the American Heart Association.
-Wes
* Please note Minnesota's obesity ranking.
Nashville, TN was heralded as the worst city. (St. Louis, Detroit, Pittsburgh, Dallas-Fort Worth-Arlington, Columbus, Cincinnati, Las Vegas, Cleveland and Indianapolis round out the loser list.)
Wow.
Now cities have rankings compiled by donation amounts to the American Heart Association! Go Red!
So come on now, Nashville and other bastions of womanly insensitivity. Stop being so policitally incorrect! Get your act straight, for goodness sake! Take it from us guys. Conform.
Or else you're going to keep getting, er, well, um, publically bitch-slapped by the American Heart Association.
-Wes
* Please note Minnesota's obesity ranking.
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